Pilot Project: The Clinical Nurse Leader Role

Introduction and Background

Most hospitals face a number of challenges in their daily operations that affect patient and staff outcomes. However, few hospitals have established a nursing leadership role to help address the issues and concerns raised by nurses. Clinical nurse leaders (CNLs) are specifically trained to handle such challenges in clinical settings and promote quality patient care. Through their intervention, quality hospital care can be achieved.

St. Joseph General Hospital, located in Iowa, offers a range of in-patient and out-patient care services. Like most hospitals, it faces a number of internal and external challenges that need to be addressed. The hospital is understaffed. It also has limited bedside expertise, high patient acuity, and low transitional care. Thus, the hospital requires a clinical nurse leader’s intervention to improve its clinical care (American Association of Collegiate Nursing [AACN], 2007). Recent research studies have established specific care quality indicators that can be applied in hospital settings. The assessment of quality patient care is often based on indicators of clinical care such as the “34 measures” devised by CMS (AACN, 2007). Nurse leaders who specialize in inpatient care can help coordinate care services, which will lead to improved staff and patient outcomes.

Description of the Project

A new position of a clinical nurse leader (CNL) was created at St. Joseph General Hospital early this year. The nurse leader role entails care planning, coordination of care, facilitation of transitional care, promotion of quality care by ensuring that nurses not only adhere to the principles of evidence-based practice but also liaise with the other practitioners to improve interdisciplinary communication. The nurse leader also mentors the other nurses and facilitates positive nurse-patient relationships. The medical-surgical unit has been selected as the pilot unit for the implementation of the clinical nurse leader role that is scheduled to start in January 2014. The pilot project will run for a period of three years. The unit manager will evaluate the project based on two validated tools: the HCAHPS score and the CMS score. These measures will serve as indicators of quality care. Also, the nursing turnover levels will be used to determine the patient and staff satisfaction levels.

Implementation

Work Analysis

The nursing staff at St. Joseph General Hospital’s surgical unit comprises nine full-time employees (FTEs). They include four RNs, three LPNs, and two aides. In this paper, the work analysis revealed that the nurses are responsible for planning and administering patient care to patients in the unit (see appendix 1b). They also evaluate the patients’ care needs and coordinate care services within the unit. The work analysis achieved three outcomes. First, it enabled the unit manager to determine the appropriate staffing level for the unit. Second, it also aided in staff scheduling, whereby each nurse’s off-duty days and vacation requests were considered in workload management. Third, it helped the unit manager to allocate staff on a shift-by-shift basis as determined by changes in inpatient needs. The analysis revealed that due to heavy workload, nurses spent less time providing personalized care for each patient.

A work analysis questionnaire (see appendix 1a) was used to collect the data. The work analysis findings (see appendix 1b) indicated that the unit has deficits in workload management, staff reallocation, and staff scheduling. It is believed that the pilot project will improve patient satisfaction, staff utilization, nurse satisfaction, and productivity of the medical/surgical unit staff. The questionnaire addressed four core areas of workload management. These included the time-demanding activities, the time-wasting activities, the patient medical records/documentation and the nursing practice standards.

On a normal working day, the surgical unit nurses are expected to provide quality nursing care according to the hospital’s policy and state standards. They also have to inform the physician about the condition and care needs of each patient in the unit. The unit nurses also have to administer medications such as IV therapy in safely manner and according to the physician’s orders. These findings were revealed during the work analysis process. Besides workload, work analysis revealed the extent to which the unit staff adhered to safe practices. Medical/surgical nurses lift or move supplies when delivering care and therefore, safe lifting practices are required in the medical/surgical unit.

Recommended Changes

Since the data collected revealed that less time is spent on bedside care, changes in the nursing roles and workload can help increase the time spent on bedside care. It is recommended that patient acuity standards be developed to help determine the amount of time allocated for each patient (Krause, 2007). Patient care needs vary from one patient to another. This implies that the time spent with each patient cannot be the same. The standards will help define the unit of nursing care, which should be adjusted to reflect patient acuity. Standards will also help nurses to assign medical procedures including x-rays and lab tests to the other practitioners. This will allow them to direct their time and efforts to patient care.

Work standards based on patient census data and the available nurses in the unit will help increase the time spent on bedside care in this unit. The patient’s estimated duration of stay in the hospital and the predicted hospital occupancy will help the unit manager to make accurate staffing decisions. This means that staff allocation will only be based on the needs of the patient. The work standards serve as some kind of workload management systems that determine the “amount of care required by a given patient” (Krause, 2007, p. 22). Thus, an effective care plan for each patient can be developed in the surgical unit based on each patient’s care needs. However, the surgical unit manager will have to “define, implement and maintain a system for determining patient requirements based on demonstrated patient needs, priority of care and available nursing interventions” (Krause, 2007, p. 23). The patient acuity standards and role delegation will help the unit manager in shift planning.

The Staffing Plan and Pattern for the Surgical Unit

The staffing patterns for the surgical unit must reflect the unit patients’ care needs. A good staffing pattern will enhance productivity and patient satisfaction. The proposed staffing plan will be based on the current staff (nine FTEs) in the surgical unit. The unit manager will employ, on a part-time basis, two RNs and one LPN. Also, to raise staffing levels in the unit, an employee utilization plan will be implemented. This will entail “setting the performance expectations for the unit” (Pattan, 1992, p. 36). There are various departmental factors that affect employee utilization in a surgical unit. Unnecessary delays, lack of proper staff scheduling and poor shift/vacation planning are some of the controllable factors while uncontrollable factors include staff demand fluctuations (which may affect hiring of part-time employees), the doctors’ orders and staff sick leaves.

The unit manager, based on the utilization target of the unit, will determine the appropriate staff utilization using different approaches. According to Pattan (1992), there are three methods for estimating staff utilization. These include the assessment of delays to identify and eliminate avoidable delays, the re-examination of the unit’s utilization levels and the determination of the appropriate workload level based on the number of shifts. This project relied on the last method to determine the level of staff utilization in the unit (attached as an excel spreadsheet). The spreadsheet presents the appropriate staff for the unit based on the patient-acuity standard. The procedure for determining the staffing level involved the determination of the number of activities that each nurse performs during one shift multiplied by the time required to perform each activity. The hours for each FTE were corrected for sick leave days and vacation days.

The Clinical Nurse Leader’s Position

In the surgical unit, quality nursing care promotes positive patient and staff outcomes. In this project, to implement the proposed quality processes, a complete cultural change on the part of the staff is required. The unit needed a Clinical Nurse Leader (CNL) to help the nurses to understand the benefits of changing the current staffing practices. The CNL must have the qualities of a transformational leader to influence the employees to embrace the new change. To effectively bring about change in the surgical unit, the CNL must have two important transformational leadership styles. These include collaboration and democratic leadership styles.

In every hospital department or unit, there must be a transformational leader who is visionary to lead the other nurses. Besides being visionary, the CNL should have excellent communication and interpersonal skills to lead the other nurses (Hall, Doran, & Pink, 2004). This will help the leader to influence the other employees and change the organizational culture in a way that promotes performance in the unit. According to Hall, Doran and Pink (2004), “we have sought prediction and control, and have also charged leaders with the role of providing everything that was absent from the machine: vision, inspiration, intelligence, and courage” (p. 19). This implies that, in order to transform the unit, the new CNL must promote evidence-based practices.

The role of the CNL comprises of five core elements. The CNL is involved in the coordination of patient care in the surgical unit to ensure that each patient’s needs are addressed. The CNL also notifies physicians about patient care needs or changing condition. He or she also facilitates the adoption of quality improvement measures in the unit. Communication with family about the patient’s condition is another key role of the CNL. The CNL also mentors and trains the new nurses in the unit on various procedures and standards of bedside care. The complete description of the CNL’s role can be found in the appendix section (see appendix 2).

The Recruitment Plan for Clinical Nurse Leaders

The challenges of under-staffing and high patient acuity motivate most hospitals to create a new nursing role. According to Hall, Doran and Pink (2004), a good recruitment plan should have the following five key elements: (1) an analysis of the nursing demand/supply; (2) clear objectives; (3) activities to achieve these objectives; (4) implementation strategies; and (5) a feedback mechanism to help evaluate the plan.

Therefore, the hospital’s chief nursing officer must first seek support from the hospital management. In seeking management approval, he or she will present the details of the CNL role and a description of how the new role will promote quality patient care in the institution. After gaining management approval, the next step involves candidate selection and interviewing. The chief nursing officer, in consultation with other leaders, will determine the qualities and skills of the CNL. The new CNL will be selected from the existing nursing staff. Interviews will be conducted and the top candidates (preferably experienced RNs with baccalaureate degrees) selected. The selected candidate will undergo a CNL training program and be awarded the relevant certifications upon successful completion. A summary of the recruitment plan is presented in the table 1 below:

Table 1: The recruitment plan for clinical nurse leaders.

Goals Activities Timelines Persons Responsible
Seeking management support
  • To seek leadership support
  • To define the new CNL role in the hospital
  • To determine how the new role will improve patient care
  • Holding discussions with hospital management
  • Consulting clinical partners
  • Delineation of the CNL tasks
1-3 weeks

1-2 weeks

1 week

Chief nursing officer
Unit nursing managers
Other nursing leaders
Candidate selection
  • To select potential candidates from the current nursing pool
  • To conduct interviews
  • Developing the selection criteria
  • Conducting interviews
1 day

3 days

Chief nursing officer
Unit nursing managers
Human resource managers
Other nursing leaders
Education/ training
To train successful candidates for the clinical nurse role
Candidate training in partner nursing schools 1 month Chief nursing officer
Nursing lecturers
Other nursing leaders

Candidate Interviewing and Selection

After reviewing applications from qualified candidates, the chief nursing officer and the hiring manager will develop an interviewing plan for the candidates. A panel comprising of the chief nursing officer, the hiring manager, a front-line staff and the unit manager will conduct the interviews. The hiring manager will evaluate the candidate’s interpersonal skills as the CNL will be expected to work with the other practitioners including the physicians, the pharmacists and the support staff. A unit nursing manager and a front-line nurse will also be involved in interviewing the candidates. Since the candidates will come from the existing nurses, a peer interview process will be used to select a suitable candidate for the CNL’s position. Before conducting the peer interview, the human resource department will provide adequate training for the interviewing team. This will ensure that the interview panel understands the different aspects of interviewing including the appropriate interview questions to ask the candidates.

The interview question will cover the candidate’s employment history, the job profile (tasks and responsibilities), leadership styles, working conditions, the organizational culture of the institution, compensation, candidate’s proposed care improvement strategy and terms of employment. A sample of the interview questions can be found in the appendix section (see appendix 3).

Orientation Training Plan

The CNL role requires skills in critical thinking, communication, collaboration and patient assessment. In a surgical unit setting, the clinical nurse leader is expected to lead the unit staff and ensure that nurses adhere to evidence-based practices. Thus, an orientation plan to the new CNL role will be important for the selected candidate. The orientation training will equip the new CNL with the necessary skills to offer competent leadership in the unit. Marquis and Huston (2009) establish a link between lack of proper orientation or training and high nurse turnover rates. The proposed orientation plan will equip the new CNL with basic skills to perform his or her role.

The orientation plan will comprise of the following four elements:

  1. overview of the department/unit, patient care needs and staffing needs;
  2. a skill assessment;
  3. orientation training; and
  4. an evaluation plan. The overview of the unit will cover competencies specific to the CNL role (see appendix 4).

Performance Evaluation Process

The unit manager will evaluate the new CNL based on the current evaluation criteria of the hospital (see appendix 5). The performance appraisal will focus on staff satisfaction, interventions to improve the quality of care and the operational integration that will come with the creation of the CNL role. In particular, the appraisal will focus on staff management, skill development and role delegation/supervision. The findings will provide a benchmark for performance improvement in the future. The Surgical Care Improvement Project (SCIP) assists hospital managers to “design effective strategies to reduce common surgical wound infections, blood clots, postoperative heart attack and ventilator-related pneumonia (AACN, 2007). To reduce these complications, the surgical unit has to implement evidence-based practices. Therefore, improvement in patient outcomes in the surgical unit will be one of the performance measures of the CNL role.

Surgical complications also affect patient recovery resulting in delayed discharge. To prevent post-operative infections, the CNL must implement specific measures such as VTE prophylaxis and proper antibiotic use. Performance evaluation will be based on monthly data (patients’ duration of hospital stay, staff feedback, medication errors, adverse events, etc.). With regard to staff management, the performance indicators will include appropriateness of care (time frame, follow-up, nature of RN interventions), staff reallocation (patient-staff ratio) and staff turnover rates. The CNL’s supervisory role will be evaluated based on the following criteria: the CNL professional standards, the quality of patient care, the assignment of tasks and the level of coordination of care. A monthly stakeholder meeting will discuss the data, gauge the CNL’s performance and recommend the areas that need improvement.

Evaluation

Evaluating the Project’s Effectiveness

The proposed pilot project will be evaluated based on the nurse turnover rate, patient care measures (CMS scores) and nurse/patient satisfaction. This data will be collected on a quarterly basis starting from January 2014. The composite CMS scores of cost and quality of care will be used to measure incidences of pneumonia, acute myocardial infarction and congestive heart failure (CHF) in patients in the unit. The same scores after one year (2015) should reflect a decrease in surgical-related infections.

The pilot project will also be evaluated based on nurse turnover rates. If the project is successful, the quarterly turnover rate in the unit will be expected to decline. Satisfaction surveys (patient, nurse and physician satisfaction) will also help evaluate this project. The patient, nurse and physician satisfaction scores (based on the Linkert scale) will be expected to increase following the implementation of the project. The pilot project will also be evaluated based on the HCAHPS scores, which will determine the project’s role in quality improvement (AACN, 2007). It is expected that, after implementing the project, the unit will achieve high HCAHPS scores (above 50 percent).

Evaluation Tools

As stated before, two evaluation tools will be used to assess the project. The Centers for Medicare and Medicaid Services’ (CMS) measures and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey tool (AACN, 2007) will be used to evaluate the quality improvement aspect of this project.

Data Collection, Analysis and Dissemination

Survey questionnaires will be used to collect data about patient, physician and nurse satisfaction. The survey will be conducted on a quarterly basis. Patient surveys will cover the number of new admissions, the patient’s care needs, delays in receiving care and the type of physician orders required. The number of medical errors, such as wrong dosage or administration of antibiotics, will also be evaluated. Physician and nurse surveys will cover issues of quality, workload management, staff reallocation and interpersonal communication. Data from these surveys will reveal whether the implementation of the pilot project improved the quality of care, staff/physician satisfaction and staff retention.

Several statistical approaches will be used in the analysis of the survey data. Correlation analysis will help determine the trends in the two measures (CMS and HCAHPS). Descriptive statistics will also be used to annotate the data. After the analysis, the findings and recommendations will be communicated to the chief nursing officer and the unit managers. The findings will then be made available to the staff, physicians and the public through St. Joseph General Hospital’s website.

Evaluating the Final Outcome

A number of indicators will be used to determine whether the project achieved its goals. Increase in patient volume, consistent staff and patient satisfaction levels, increase in staffing levels and improved unit leadership are indicators of a successful project. It is projected that one year after implementing the project, the CNL role should be implemented in two other units in St. Joseph General Hospital. However, if these goals are not met within a year, the project will be revised. In the revised version, the maximum number of patients that the clinical nurse leader will handle will be 20. Also, unlike in the current project, in the revised project, the CNL will be trained in partner nursing institutions during his or her orientation. This will allow him or her to learn the new concepts and issues associated with clinical leadership. A summary of the evaluation criteria is presented in table 2 below.

Table 2: The Evaluation Criteria for the Pilot Project.

Measurable outcome Data Collection Plan and Tool Responsible Person Outcomes
Staff Management
Staff turnover
Nurse satisfaction
Patient satisfaction
Physician satisfaction
Quality ImprovementStaffing Outcomes
Survey questionnaires

CMS and HCAHPS measures

Surveys; secondary data

The chief nursing officer

The unit manager

The unit manager

  • Reduction in staff turnover
  • Increase in patient, physician and nurse satisfaction
  • Increase in CMS and HCAHPS scores following implementation of the CNL role
  • Reduction in medication errors

References

American Association of Collegiate Nursing [AACN]. (2007). A White Paper on the Role of the Clinical Nurse Leader. Web.

Hall, M., Doran, D. & Pink, G. (2004). Nurse staff models, nursing hours, and patient safety outcomes. Journal of Nursing Administration, 34(1), 19-25.

Krause, T. (2007). The effective safety leader: leadership style and best practices. The Magazine of Safety, Health and Loss Prevention, Occupational Hazards 69(12), 19-24.

Marquis, B. & Huston, C. (2009). Leadership roles and management functions in nursing: Theory and application. Philadelphia, PA: Lippincott Williams & Wilkins.

Pattan, J. E. (1992). Developing a nurse recruitment plan. Journal of Nursing Administration, 6(3), 33-39.

Appendices

Appendix 1 (a): Work Analysis Questionnaire

  1. List 3 top activities in which you spend your time?
    1. …………………………….
    2. …………………………….
    3. …………………………….
  2. What are the roadblocks for you getting your work done?………………………………………………………………………
  3. What wastes your time?…………………………………………………………………
  4. What is working well?……………………………………………………………………
  5. What is not working?……………………………………………………………………..
  6. How much time do you spend daily on paperwork?……………………………………………………………………
    1. How much duplicative paperwork do you do?……………………………………………………………………
    1. Where can we streamline documentation?………………………………………………………………………..
    1. Is there anything you believe we could eliminate?………………………………………………………………
  1. Do you have the appropriate and enough equipment to get your work done? If not, what are the top three priority areas for resolving equipment-related issues?……………………………………………………………………………………………………………..

Other comments you would like to share……………………………………………………………………..

Thank You.

Appendix 1 (b): Work Analysis Findings (Surgical Unit)

Measurement/score Findings
Workload
  1. Nurses’ top ways of spending time
  1. Workplace challenges
  1. Time-wasting activities

Staff management

  1. Staff allocation
  1. Assigning duties
  1. Vacations and sick leaves.

Staffing levels

  • many of the unit nurses spend their shift hours doing patient rounding, performing procedures, following up with physician orders and administering antibiotics.
  • the nurses reported heavy workload, poor work environment, horizontal violence and burnout as the common challenges they face in the unit.
  • checking the patient’s medical records and transitional care systems were identified as time-wasting activities.
  • staff allocation in the unit follows no particular guideline; the unit is allocated the nursing staff based on patient volume not acuity.
    assigning duties does not take into account patient acuity and number of hours required to provide adequate bedside care.
    vacations and sick leaves are not well managed resulting to staff shortage, work overload and staff burnout.
    the unit has nine FTEs, who also serve the other units. This implies that the unit is understaffed and lacks an appropriate skill mix.

Appendix 2: The Clinical Nurse Leader Position

Roles Specific duties and responsibilities
  1. Coordination of interdisciplinary care
interdisciplinary patient rounding; administration of medications; diagnosis/testing; staff education; assessment of patients’ care needs
  1. Liaison with other practitioners
informs the physicians of a patient’s treatment needs; facilitating interdisciplinary communication; notifies the physician when the patient needs urgent medical attention.
  1. Quality Improvement
assesses unit performance based on hospital data and reports; suggests areas that need improvement; discusses the unit performance issues with the unit manager; implements evidence-based practices in the unit
  1. Educating and mentoring new nurses
training nursing staff on procedures and policies of quality patient care
  1. Communicating with family
educates the patient’s family about the illness and the treatment options; communicates any family fears or concerns to the nursing staff and the physician

Appendix 3: The behavioral Interview Questions for a Clinical Nurse Leader

  1. How can you describe your leadership style?
  2. Do you consider yourself a visionary leader?
  3. What interpersonal communication skills would you consider to be important for a nursing leader?
  4. How would you handle employee conflicts and horizontal violence in the workplace?
  5. What strategies will you employ to reduce nurse turnover in the surgical unit?
  6. How would you reallocate staff to ensure that patient care needs are well taken care of?
  7. What measures will you use to benchmark quality improvement in your unit?
  8. As a transformational leader, how will you handle noncompliant staff in your unit?

Appendix 4: Competence Checklist

CNL Role Competences
Assessment
  • Evaluate condition/clinical situation
  • Systematic assessment approach
  • Use of objective data
  • Data organization
  • Prioritizing data
  • Describing the problem/situation
Diagnosis
  • Data analysis
  • Identifying the problem
  • Proper diagnosis
  • Informed decision making based on cost-effectiveness
  • Analysis of the causes
Planning
  • Defines goals and outcomes of nursing interventions
  • defines realistic and measurable goals
  • Identifies patient assessment options.
Evaluation
  • ability to reassess the situation
  • developing an evaluation plan for a nursing intervention

Appendix 5: Performance Evaluation Form

Action Area Expected outcomes
Differentiates Between Ethical and Legal Issues
  • Adherence to the standard of care as it relates to participating in the identification and resolution of ethical concerns, utilizing professional codes of ethics within institutional parameters
  • The Health Insurance Portability and Accountability Act (HIPAA) of 1996 delineates the patient’s rights and responsibilities related to confidentiality of information, personal privacy and self-determination (HIPAA definition, HHS Office of Civil Rights)
  • Differentiates assessment or care delivery and treatment based on client needs; advocates for appropriate care, including working through an appeals process with insurance carriers when needed
  • Provide a staff mix appropriate to the intensity level of patients as supported by evidence or research-based staffing pattern designed for ambulatory care settings
Laws that Govern Practice
  • Nurse Practice Act
  • American Nurses Association (ANA) Code of Ethics for Nurses
  • ANA Ethics in Nursing: position statement and guidelines
  • AAACN value statement/ethic codes
Ethical Principles
  • Communicate work to staff and patients
  • Provides a voice for patients and educates patients on their rights: Patient’s Bill of Rights
  • Autonomy: self-determination, the freedom to choose one’s own course of action, Advanced Directives, or Patient’s Proxy
  • Beneficence: doing good
  • Non-malfeasance: acting in a way that avoids, harms (either intentional harm or harm as an unintended outcome)
  • Confidentiality: to protect the patient’s and family’s right to privacy, guarding information that the nurse or institution holds regarding the patient (HIPAA)
  • Justice: fair, equitable distribution of resources
  • Veracity: truth telling
  • Fidelity: faithfulness